Political Analysis of Health Reform in the Dominican RepublicGlassman, A., Reich, M., Laserson, K., and Rojas, F.

Presented by B.E. NillosMAHESOS

Introduction

•Latin America in the 90’s initiated Health Sector Reform

•Little attention on political challenges associated with health sector reform

•Reform = profoundly a political process that affects the allocation of resources in society, and often imposes significant costs on well, organized, politically powerful groups.

Health Sector Reform

•Activities undertaken cooperatively between the international development banks and a national government to alter in fundamental ways the nation’s health financing and health provision policies.

•Definition is limited to the interaction between international lending agencies and national government bodies.

Health Sector Reform

•Primary Goal = self-sustaining national health care financing system

•Secondary Goal = greater coverage for basic health services at a lower cost per person, rationalized decision-making within public sector health agencies, institutional reform, expand access for disadvantaged populations

Political Analysis = Framework for Analysis*1. Define the content of the policy under

consideration2. Identify political players, their interests

and relationships3. Analyze opportunities and obstacles to

the policy4. Design political strategies5. Assess the potential and actual impacts

of proposed strategies

Health Reform in the Dominican Republic: Attempts•“modernization” of the health system

(UNDP) – no follow-on activities•Introduced “National Health Law” – not

pushed through•Creation of National Health Commission

(CNS) and Office of Technical Coordination (OCT) – drafted “white paper”, became basis for reform proposal and is the focus of the analysis

Political Environment of the Dominican Republic•1988 – third lowest GDP per capita in the

Americas•Limited pluralist system without

accountability, without an explicit political idealogy

•Most decisions were taken by the President personally (Joaquin Balaguer).

•SESPAS is major health service provider but Secretariat of the President is significant source of financing

Analysis of the OCT Reform Proposal (White Paper)•Policy Content:

▫Principles: universal access, equity, solidarity, quality, freedom of choice, efficiency, efficacy and transparency

▫Strategic Guidelines: design of single system, shift to preventive services, strengthened regulatory role of state, increased financing, guaranteed benefits for affiliates, efficient systems and social participation

▫Policy Mechanisms: new model, decentralization, role transformation and competition.

Analysis of the OCT Reform Proposal

•Players▫Public Sector: SESPAS (High Power, Low

support), IDSS (Medium power, low opposition)

▫Private Sector: highly opposed to regulation (moderately opposed, high power)

▫Unions: AMD (High power, highly opposed)▫Political Parties: Leonel Fernandez, PLD

(High Power, Low Support)▫NGO’s: (Low power, Low opposition)

Analysis of the OCT Reform Proposal

•Opportunities and Obstacles:▫OCT has ample financial resources, but

limited staff▫Broad consensus that health system has

multiple problems and needed serious improvement.

Analysis of the OCT Reform Proposal

• Strategies:1. Create common ground2. Create a common vision3. Define the decision-making process4. Mobilize and prepare key actors5. Initiate pilot studies6. Political parties/new government7. Initiate strategic communications8. SESPAS and IDSS: manage bureaucracy9. Strengthen Alliances with Int’l organizations10.Involve “Friends” in the Planning11.AMD and IDSS: Create strategic alliances

Conclusions

•Factors that affect pace and feasibility of Health Sector Reform Proposals

1. Leadership of the reform2. Political strategies adopted by the

reform group3. Location of the reform group4. Ownership of the reform5. Political language of reform6. Political timing of the reform

END“Politics is medicine in a large scale” - R. Virchow